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Gay men in England who have recently become HIV positive
describe a complex web of factors which may have contributed to their
infection, according to a qualitative study recently published in BMJ Open.

“Individuals who experienced multiple stressors, gradually
over the life course or more suddenly, were especially vulnerable to HIV
and being drawn into sexual risk situations, while the social environment
created a context that enabled risk of HIV infection,” the researchers
write. Individual and interpersonal factors frequently combined with community
or structural factors, such as the widespread use of dating apps, chemsex and
HIV treatment, as well as changing perceptions of the seriousness of an HIV
infection.

The study paints a picture of the personal and social contexts
within which gay men are acquiring HIV in the UK. Each year, more than half of
HIV diagnoses in the UK are in gay men.

The study

In early 2015, Annabelle Gourlay of University College
London and colleagues recruited 21 gay men who had recently been diagnosed with
HIV in London or Brighton and who had, tests showed, very recently acquired HIV (usually just a few weeks before diagnosis). They were interviewed on average six months after the estimated date they were infected. The researchers selected men infected recently on the assumption that they were more likely to recall accurately how they got infected than men who acquired HIV longer ago.

Participants were aged between 22 and 61 (median 38) and were mostly white, well educated and employed. The in-depth
interviews covered personal background, moving to London/Brighton and
experiences of this transition (if applicable), life in recent years before HIV
diagnosis, relationships, and perceptions of the circumstances at the time of
HIV infection.

The researchers note two potential limitations of their
study. Firstly, the experiences of white gay men in large urban centres may not
be generalisable to men in other ethnic groups and geographical areas. Secondly,
responses may have been limited by social desirability bias, in other words a
tendency to answer questions in a way that will be viewed favourably by
others.

Individual and interpersonal factors

Many respondents described difficult experiences during childhood
which had long-lasting impacts on mental health, drug use and support. Many
described dysfunctional or superficial relationships with their parents, family
members who had alcohol or mental health issues, or being bullied at school.
One man said:

“My father was…an alcoholic and he used to beat my mother
and me…That may have had some impact on how destructive one is, and the fact I
never had any unconditional love is something that I have struggled with in
adulthood.”

One man who said he
had never ‘felt nurtured’ by his parents explained:

“I always need validation from people…and that manifests
itself in a sexual context.”

A few men grew up
in environments where gay men were highly stigmatised, which could result in
repressed sexuality or low self-esteem. While most participants had ‘come out’
as teenagers or young adults, others only disclosed their sexual orientation in
their twenties or thirties. In some cases, this was associated with resentment
of having missed opportunities and a desire for sexual exploration.

“Growing up in an environment where you are getting to
know yourself quite late, you get to…thinking about experiences and seeing
other sexual stuff that you might not have needed to think about before because
you are a bit behind…You know, am I missing out on stuff?”

A number of men
were exposed to multiple psycho-social risk factors and the combination could
be devastating.

“I was probably overwhelmed, you know. I wasn’t in a
stable place, I wasn’t in a stable relationship, I wasn’t stable financially and
I had just suffered some pretty serious losses in terms of my immediate family.
It was kind of all over the place really.”

Some men
experienced a ‘mid-life crisis’.

“I mean it probably was the perfect storm you know, they
[drugs] got me at a time…mid-forties when I wasn’t that secure, there were a
few issues, I was looking for fun…it was an escape and it seemed at the time
that it was…enjoyable.”

Emotional trauma could make men re-evaluate the potential
costs of unsafe sex.

“I didn’t value my life… Because so much had happened and
I’d been through so much in the past three, four, five years with…break ups and
losing everything and emotional things and deaths and God knows what else, it
almost becomes a bit “all my life has just been so crap anyway what’s the
point, do I really care if I get it [HIV] anyway?”

Community and structural factors

Men were attracted to London and Brighton for their
open-minded culture, freedom and social opportunities. Almost all had met
partners at saunas, clubs, chill outs (parties often involving drugs and group
sex) or cruising grounds. The temptations of the gay scene could be hard to
resist.

“You go to Vauxhall [gay district in south London] on a
Friday night as a gay man and don’t come home until five days later. I think
there is so much to tempt young people these days, I include myself in that.”

Dating apps provided convenient access to multiple sexual
partners for many participants, regardless of age. They could also
introduce men to chill outs and chemsex, and some interviewees felt that they
promoted promiscuity and irresponsibility. Several men recalled changes in the
cultures of sex and drug use on the gay scene.

“Drugs have changed…there are more choices…GHB,
mephedrone…which I was quite scared of in the beginning…but then it’s
normalised in the gay scene and you just tend to do what other people do. Same
thing goes for injecting. I mean these days it’s not seen as so scary.”

Interviewees,
especially middle-aged and older men, described the shifting perception of HIV
in the gay community.

“I think in London
it's almost got to the point where people are not that concerned about it
anymore. It's not looked at as a death sentence. I remember reading an article
by a doctor, which I know a lot of gay people seem to have read…that he would
rather have HIV than diabetes.”

Thanks to the availability of effective HIV treatment and
good medical care, HIV was widely perceived to be a manageable condition. This
affected behavioural norms and attitudes to risk.

“Everyone knows somebody positive now and knows that
they're fit and healthy and they take a few pills a day…That's a huge factor in
why so few people use protection anymore…because it has become a treatable
illness…I think it changed everyone's risk calculations, because even if the
worst did happen, it was no longer the worst.”

Some of the younger
participants made conscious choices to engage in condomless sex, including with
HIV-positive partners who had an undetectable viral load. Several had used post-exposure
prophylaxis (PEP) and a few had unsuccessfully tried to get pre-exposure
prophylaxis (PrEP) from their sexual health clinic. (PROUD study results were
first reported in October 2014 and the interviews were conducted in early
2015.)

Generally, many respondents felt that there was a sense
of apathy towards risks and susceptibility to HIV in the gay community. They
attributed this to the availability of HIV treatment and newer prevention
options, the increasing understanding of undetectable viral load, declining
stigma and changing perceptions of HIV.

A complex interplay of factors

While a few interviewees explained their infection in terms
of a single factor, most participants thought that a combination of factors contributed
to risk behaviours and HIV infection.

“The sex and the drugs and the apps all intertwined
simultaneously and I can’t really say which one led to the other.”

The researchers note that there was often an interplay
between individual, community and structural factors. For example, one man in
his twenties felt that his self-harming sexual behaviours stemmed from
childhood and a violent relationship with his mother, but also highlighted the
role of the ‘abusive’ environment, including gay saunas.

“I think with the sex, I think it’s…environment,
especially in South London. The increase of risk sex, chemsex, is becoming an
epidemic, in my opinion. You hear of so many young gay men now who are
positive…and through this lifestyle. It’s very hedonistic, really nasty…I
think, subsequently, living in South London has made me get HIV.”

Psychological issues
and drug use were often mentioned in combination. For example, a man in his
forties identified the important factors in his HIV infection as:

“The drugs…but also depression because I didn’t care
about taking risks…I gave up.”

Some participants
who had experienced stressful events suggested that changing perceptions of HIV
had consciously, or subconsciously, influenced their behaviour. Risk-benefit
decisions were altered.

“When we were young adults, the fear of God was put into
us. If you got it you died…Now it is manageable…you could live a normal life…I
think the trauma I have gone through has changed what I perceive as real risk
in life… There are far more important things…So it was a combination of all
those different aspects, I had come to the conclusion that if I did become
HIV-positive it wouldn’t be a big event in my life.”

Conclusions

The researchers
worked with a socio-ecological framework to guide their analysis. (See graphic here). This suggests
that the factors which may contribute to HIV infection can be considered to
operate at three levels:

improved clinical
assessments to identify HIV-negative men who need more support

tailored
psycho-social support for young gay men

outreach activities
to link socially isolated men to peer support

community education
about chemsex

training to help health professionals have culturally competent discussions with gay men about
chemsex and risk behaviour

counselling interventions provided
on dating apps

programmes to raise
awareness of the social and psychological implications of an HIV diagnosis

access to PrEP.

Reference

Gourlay A et al. A qualitative study exploring the social and environmental context of recently acquired HIV infection among men who have sex with men in South-East England. BMJ Open 7:e016494, 2017. (Full text freely available.)

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NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member
of your healthcare team for advice tailored to your situation.